An Osteopathic Approach to Performance

Tue Aug 12, 2014 by Jelle Zandveld

If you’re reading this article, you’re probably familiar with the Body-Swing Connection™. It’s the fundamental concept taught in TPI’s Level 1 Seminar. Very simply, many common swing faults can be traced back to the body’s inability to move correctly. The concept seems so simple and yet it’s still a relatively new, but rapidly growing, methodology for increasing golf performance; improve mobility, stability, strength & power and your client will have a much better chance of swinging more efficiently and with a reduced risk of injury.

The pyramid approach that TPI promotes where the teaching professional, medical professional and fitness professional work as a team to identify, treat and rehabilitate dysfunction in the body works extremely well. Those physical improvements can then be realized and leveraged by the swing instructor with improved swing mechanics. Brilliant. But let’s take a moment and talk about the assessment and treatment portion of this equation and see how osteopathic medicine may be the missing link in the assessment and treatment phase with your players.

Great minds like Gray Cook and Dr. Greg Rose have developed outstanding assessment tools and protocols for identifying and evaluating movement dysfunction, as well as ways to treat the dysfunction. One of the primary concepts taught in both TPI assessments and FMS assessments is the Mobility/Stability model. As Gray Cook states: “The body works in an alternating pattern of stable segments connected by mobile joints. If this pattern is altered, dysfunction and compensation will occur.” This concept, which any TPI or FMS Certified Professional is familiar with, clearly demonstrates how dysfunction in one area can lead to injury and pain in another area. The body is a marvelous series of connections, each affecting function in other areas. This concept of the body being “connected” is very similar to the holistic approach to medicine that is known as osteopathic medicine; a medical practice seen more and more in the treatment rooms across a huge variety of professional sports.

Osteopathy, the way I work, is a medical practice based on a holistic approach to medicine that focuses on the interconnectivity of all human systems (structural-functional system, visceral system and cranio-sacral system). By addressing each of these systems holistically and using manual techniques as well as proper nutrition, we can unlock the self-healing possibilities of the patient and restore mobility.

The 5 Principles of Manual Osteopathy

  1. Life is Movement
    Everything must be mobile. Every anatomical structure in the body needs freedom to move, not just the structures of the musculoskeletal system. Organs should be able to move freely as well. Fluids (for instance blood or lymph) must be able to flow without obstruction. When mobility is restricted, dysfunction and disease can result.
  2. Structure and Function
    Structure and function of the body influence one another and are reciprocally interrelated (function governs structure, structure governs function). A disturbance of function can be identified through a difference in movement of a structure. Manual osteopathy tests and diagnoses the movement of the different structures to find the disturbances in function.
  3. The Law of the Artery
    Every tissue in the human body must be well nurtured and toxins should be disposed of. A long lasting disturbance of this nurturing and disposal process can change the quality and mobility of the tissue. This counts for all body fluids (arterial and venous systems, lymphatic fluids, brain fluids, etc.)
  4. The Unity of the Human Body
    The human body functions as a unit. All mechanical structures, tissues and organ systems are connected through the connective tissue, nerves and fluids. Abnormalities of normal function and mobility in any of these individual components will have consequences in overall physical function. In osteopathic medicine, the human is always treated as a whole, not just through the lens of a specific dysfunction or illnesses.
  5. The Body Can Heal Itself
    The ability of our body to either stay healthy or to recover when ill, is a result of its self-healing powers. We see this everyday and think nothing of it. Broken bones heal, the immune system fights off an infection, blood clots, etc. The body is capable of incredible self regulation and healing when systems and structures are functioning properly.

So how does an osteopath fit into an athletic program alongside nutritionists, chiropractors, medical doctors, physical therapists and trainers?  In my opinion, the osteopath connects all of these groups like a missing link. Let me explain. Everything you eat and drink (the work of the nutritionists) must be processed and delivered to the appropriate location via the body’s logistics system. The brain, nervous system and muscular system need the right nutrition to grow and perform. Without the right proteins, lipids and carbohydrates (etc.), there is no muscle growth, hormones cannot be produced and neurotransmitters will not be of high quality. We need rocket fuel delivered to the right location at the exact moment it’s needed. That delivery is done via the body’s logistics system.

This logistic system is embedded in our mesoderm. The vascular systems (venous and arterial) as well as the lymphatic and nervous systems are all supported by mesodermal tissue. If this tissue is somehow restricted in its movement, the transport will slow down and the organs behind this immobile structure will suffer. One of the osteopath's main roles is to find and treat obstructions in the mesoderm. We do this by looking at each of three diagnostic and treatment pillars in osteopathy - the parietal, the cranio-sacral and the visceral systems. The parietal pillar of diagnostics and treatment is similar to that of physiotherapists and chiropractors (an early offshoot of osteopathy); in short, mobilization and manipulations of the musculo-skeletal system. I will leave the cranio-sacral system and its possibilities for a later discussion. Basically, it’s the treatment of the liquids and nervous structures connecting the cranium and the sacrum (and beyond). The visceral system is the missing link!

During my study of osteopathy, I learned the importance of treating the mesoderm surrounding the visceral structures. When the viscera cannot move freely, the process of absorption and secretion is impacted. Vital nutrients cannot reach the target organs and waste is not able to exit the body efficiently. Since these toxins cannot stay in our transportation system, they have to be stored in the body. We have two systems for storing toxins: lipids and mesoderm. Most people tend to store toxins in both systems to some degree but for this article, I want to focus on the group of people that primarily store toxins in their mesoderm. This is the group of athletes that often come to me seeking help. Typically, they’ve been on an endless search for wellness. These athletes are often on medications (even more toxins to get rid of) and have followed every possible diet. Stretching, massage and fascia therapy often help, but injuries tend to return and they’re left with chronic pain.  

Upon examination, many of these individuals are characterized by a very tight system of connective tissue (the mesoderm). If this system gets jammed by too much load or tension, it can manifest in a variety of ways. When the arterial supply or lymphatic drainage systems are impaired, the system will dysfunction, causing toxins to accumulate in the muscular and connective tissue systems. This leads to abnormal levels of tension in the muscular and soft tissue structures. By interventions directed at the connective tissue, the “jammed systems” can be freed up and the physiological environment to facilitate healing can be re-established. Often, these interventions will need to be focused on areas supporting the organs themselves.

From an osteopathic viewpoint, or total body approach, there are things to be learned from understanding the impact that human organs have on a player’s physical and mental development. In anatomical labs around the world, where students and researchers work with human cadavers, the connective tissue that “bridges” the human organs is readily evident. Thomas W. Myers describes the way fascia controls movement in his book Anatomy Trains. It describes how the connective tissue creates “chains of movement”. The fascia surrounds muscular tissue and even muscular fibers thus continuing to connect the soft tissues to different bony structures. This way it can explain why obstruction in one part of the body can cause a mobility or stability problem somewhere up or down the chain or body segment. Therefore, a dysfunction in the mobility of an organ can lead to a muscular tightness or even a lesion or scar that is palpable and symptom producing in athletes. The combination of both muscular and visceral fascia and its connections describes the way I specifically look at my patients, sportsmen and golfers.

Let’s take an example of this process with a very high altitude look at how a patient with chronic lower back pain may be helped via an osteopathic approach.

I see golfers who come to me with lower back pain quite often. When trying to determine the underlying cause of the pain, I use a whole body approach and many times, I find that their back problems are caused by high tension and bad mobility of the visceral organs. Storage of toxins in the connective tissue will cause a change in the viscosity of the matrix – thus impacting negatively on the mobility of the important collagen or elastic fibers in this tissue. If the mobility of the fascia is decreased, it will be to the detriment of the golfer. How many of you look at the front of the spine? Besides training the abdominal muscles (which might be the opposite of what should be done at that moment), the ventral side is typically ignored by most. But look at just some of the anatomical connections of the front of the spine:

  • The connection of the liver to the abdominal diaphragm which connects to the ribs and spine.
  • In the gastric system, the esophagus connects to the diaphragm. The stomach is a strong muscle and if tense, will give you a flexion of the spine to release.
  • The front of the spine also connects to the ventral side of the occipital bone. You can imagine the problems being caused in the cervical spine as well as the potential for typical headaches.
  • The kidneys share their fascia with the Psoas muscle. This connection is, in my opinion, the most important cause of low back pain.
  • The kidneys, over the muscle fascia, also have a large impact on the knees, especially the patella.

Either hyper or hypo tension in the visceral system is often caused by improper nutrition. Even though this is an individual problem, some common causes are:

  • Not enough water leading to dehydration of the small intestines followed by an inability to absorb many nutrients.
  • Often seen in combination with dehydration are too much refined sugars, caffeine, alcohol and nicotine. These “toxins” cause the disbiotic intestinal flora to suppress the needed symbiotic bacteria. This is usually followed by a decrease in the absorption of the needed nutrients and opening of the intestinal tissue for toxins.

Osteopathic treatment of these structures is an important part of setting the GI-tract “free” and giving the nutritionists the possibilities to do their work. In this case, teamwork is required. The osteopath will have to reestablish the normal visceral mobility and the nutritionist will have to educate the golfer on an appropriate diet. We typically have regular sessions (usually once a month) to see if there are any restrictions, hypo or hyper tensions in all the different systems. If all fluids are flowing well, the nervous system free for motion, and the connective tissue free for movement, we have a healthy athlete.

An Athletic Development Coach or PGA Professional who struggles to attain the desired mobility and thus swing mechanics for a player, may need to consult a trained osteopath who has an understanding of golf. In these cases, mobilization of the inner organs and the subsequent release of the joints can lead to marked changes in the tension of the muscular and soft tissue systems. The human body inherently looks for balance, economy and comfort. Thus tightness and restriction in the organ (or visceral) structures and connections can lead to significant mobility issues that may impact on swing mechanics. As the respected osteopath, Dr A.T Still explained: “We can only treat the entire human body by learning about its anatomy”. Through an improved understanding of the different connections between all of the systems in the human body and not just a concentration on the musculoskeletal system, we may reach our golfing goals faster without recidivism.

In part 2 of this series on osteopathy, I will go into detail on how an osteopathic approach can be beneficial in ascertaining the root cause of specific swing faults in golfers who have been diagnosed with movement dysfunction.

Jelle A. Zandveld

Jelle A. Zandveld Eur.Ost.D.O, BSc. Reg.PT Osteopath and Physical Therapist
Director - Golf Physical Performance

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  • Trevor Montgomery

    One of the most important lessons I have had over my career to date as a physiotherapist and educator is to never discount any information. Everything you learn as it relates to treating patients has some value. That value may lie in reinforcing your current beliefs and treatment paradigms or it may add to your tool kit to make you a more versatile and effective therapist. Either way, if you don’t give the presenting information due consideration then you can do yourself and your clients a disservice (albeit through ignorance or arrogance but a disservice none the less). I remember Dr Greg Rose asking at a Medical 2 seminar I attended a few years ago: “who practices evidence-based medicine?” A group of eager hands shot up that were quickly retracted when Greg shook his head with disappointment. Whilst the original proposition for evidence-based medicine had three equally important pillars (1-the best available evidence; 2-experience of the treating clinician; and 3-the preference of the patient regarding their care), modern medicine and the funders seems to place far too much weight on the first pillar at the expense of the other two. Preferentially, Evidence-informed practice “reflects a more realistic scenario where clinicians are aware of emerging evidence, and rationally integrate new information into their clinical acumen, keeping the best interest and desires of the patient in mind at all times. This process occurs in the context of a living business, your practice, which can sometimes be unpredictable. Each patient is different. There are no formulas, no is a dynamic process” (Dr Shawn Thistle – Research Review Service, 2012). So after reading Jelle’s article (and the varied responses) I thought I would add my thoughts. The article certainly has lots to consider but not a lot I would choose to debunk. Firstly, I think that I can safely assume that Jelle does indeed see a portion of the low back pain population, be it golfers or not, that have a distinct clinical presentation and a positive response to his osteopathic approach to treatment. Why else would he take the time to pen the article? Secondly, I feel fairly justified in assuming that the effects of dysfunctional viscera and the role of the enteric nervous system are not typically at the forefront of most musculoskeletal therapists’ minds when treating such an apparently structural problem as low back pain (or knee pain) for that matter. But if we break Jelle’s approach (that most of us clearly know little about) into its component parts it gets a little more interesting. Dr Jay Shah, one of the world’s leading researchers into myofascial pain, speaks about the concept of ‘segmental spinal sensitization’. That is, if there is enough afferent stimulus (typically nociception) for long enough, the spinal cord segments (dorsal and ventral horn included) becomes sensitized. This sensitization can then sensitize (e.g. hypertonicity, allodynia or hyperalgesia) every other tissue supplied by that segment. What is worse is that there is evidence to suggest there is ‘sensitization drift’ of up to seven levels above and below the primary segment. Clinically I have seen more than enough evidence to support the existence of this phenomenon, and when approached from that perspective, patients who otherwise responded poorly to mechanical intervention get better. So for me, it is only a small step in my clinical reasoning process to see that problems with the kidneys, the adrenals glands, the fascia around them and the suspensory ligaments that support them (supplied by the renal plexus from the levels of T10-L2) can have a negative impact on the psoas major muscle which shares some direct innervation (L1-2) and sympathetic innervation (T10-T12). I have seen imaging that clearly shows a patients kidneys sitting down inside the pelvic rim, which to me, indicates some form of dysfunction in their fascial and ligamentous support structure. Dr Jay Shah spoke of an editorial, written a few years back, by one of the leading rheumatologists in the US (whose name alludes me at present) showing remorse for his professions neglect of the myofascial system and its ability sensitize the nervous system, which left unchecked can be one of the primary drivers of negative neuroplastic changes in the central nervous system. So could problems (position or otherwise) with the kidneys and the associated fascia cause dysfunction in psoas major? I have enough pieces of information for me to believe there is a definite relationship. Can myofascial dysfunction in psoas major cause pain and alterations in lumbar spine and hip mechanics? Absolutely. The proximal attachments of psoas major place it in position to create far more vertical compression on the spine than flexion (its position relative to the intervertebral flexion axis makes it a poor spinal flexion lever compared to say rectus abdominis). Could prolonged vertical compression of the lumbar spinal lead to the onset of low back pain? Absolutely. The myofascial referral pattern alone for active trigger points in psoas major lies directly down the lumbar spine with a lateral spread to the sacroiliac joints (as mapped by Janet Travell and David Simons all those years ago). Add to that, continued compression placed on the intervertebral discs by a dysfunctional psoas major which can irritate and sensitize them, leaves little doubt that any anatomical structure that sits on the same segmental ‘circuit’ as psoas major can predispose a person to low back pain. With the lumbar spine providing around 20% on the overall trunk rotation available, golfers would be a prime group to notice the relative restriction, or worse, the ‘less than ideal’ compensation strategies in their swing mechanics that can load the spine and create low back pain (it’s not uncommon for golfer’s to have a mismatch between their swing concepts and their current physical parameters). So the question is: could kidney malposition and the relative load placed on the highly innervated fascia around them cause low back pain? As Jelle attests to in his article, it is entirely plausible, and as it happens, so too is the relationship between kidneys and knee pain. One of the key roles of psoas major is to provide hip joint approximation (much like the rotator cuff) prior to hip movement, particularly hip flexion and hip abduction. A dysfunctional psoas major, manifesting in pure weakness or an inability to feed forward by way of hip joint approximation prior to hip movement (or both), typically inhibits a patient’s ability to recruit gluteus medius (for abduction) and iliacus (for flexion) in any meaningful way. Dry needle release of a dysfunctional psoas major (from a posterior approach) can see an immediate, significant and sustained improvement in both hip flexor and hip abductor strength and endurance (provided the underlying cause(s) of why psoas major became dysfunctional in the first place are addressed). Inhibition of gluteus medius and iliacus typically results in the alternative recruitment of tensor facsia latae (TFL) to assist with both movements. Unfortunately the attachments of TFL create not only hip abduction and flexion, but also internal rotation of the femur and external rotation of the tibia, typically creating in an increased rotational shear load on the menisci and the associated coronary ligaments of the knee, often resulting in knee pain. The constant increase in Q-angle from an overactive TFL and the resultant tibial torsion can also lead to ‘maltracking’ of the patella with quadriceps loading and the subsequent onset of patellofemoral syndrome. If TFL becomes overloaded and myofascial trigger points form in situ, lateral knee pain can result by way of an iliotibial band friction syndrome. Furthermore, a weak and/or dysfunctional iliacus (by way of losing the feed forward contraction of psoas major) can lead to alternative recruitment of rectus femoris as a primary hip flexor. With rectus femoris now performing two primary roles (hip flexion and knee extension), dysfunction is often inevitable and the increased tension can result in increased load the patella tendon, with degradation of the tendon and a diagnosis of patella tendinosis a possible long term outcome. For those practitioners who dismiss out of hand the possibility that problems with the kidneys (or viscera in general for that matter) could it be one of the primary drivers that cause the cascade of reactions and compensation strategies that leads to the onset of low back pain and knee pain in a percentage of golfers, you have at the very least succeeded in strengthening your current beliefs and treatment paradigms. For those of you who don’t think Greg Rose, Dr Ernst Zwick and the plethora of great minds that make up the TPI Advisory boards don’t spend time considering treatment approaches that fall ‘outside the box’, I suggest you spend some more time with these people – it may just change the way you view some of the wonderful information that sits on the ‘fringe’ of musculoskeletal medicine and may indeed make you a more effective therapist to your patients. I am very much looking forward to catching up with Jelle at the next World Golf Fitness Summit and picking his brains about a skill set that I currently lack in my tool kit, but could certainly benefit from learning.

  • Kevin Boothe

    First, I would like to thank you for the well written approach to low back pain and the golfer. The comments, rather positive or negative, suggest there is a good room for an educated discussion. Where if researched or clinically relevant, can back their opinion. I am a Physical Therapist, certified in both FMS and TPI. I proud myself by staying up to date on research and new techniques, as well as modifying various techniques to ensure that my patient/client benefits the greatest. I have also looked into returning to school through a D.O. program. What people fail to forget, is our neuro development. Visceral organs referral patterns are linked to common muscles. If the visceral organs aren't doing their job, then they can be at fault for muscle imbalances. I promote proper nutrition, as I know if I don't address this, most of my patients chronic symptoms will fail to resolve. Rather in the clinic or in the gym, I always tell my patients/clients, that the 1 hour in the clinic/gym is negated if the other 23 hours outside of the clinic/gym are not the primary focus. Such as with proper nutrition, healthy lifestyles, and/or home exercise program.

  • Jelle Zandveld

    Thank you for all comments so far, positive and negative as this makes clear there is still litlle understanding of the osteopathic holistic approach. The most critisized part was the influence of the kidney on the lower back and the unscientific side of the comment. This is very well scientific since it is based on simple anatomy and the connection that are visible when disecting the body. Pictures of this can be found in the anatomic picture books of Rohen et al for those interested enough to look it up. As for the remark that I think most issues of LBP have to do with the organs and specifically the kidneys I must say that most patients I see have been almost everywhere before seeing me. All causes of LBP not concerning the visceral component might have been treated succesfully already! The patients that keep returning to you and do not react to treatment the way you expect them to might have great benefit to an osteopathic approach as there might be other reasons for the LBP that might not be looked at yet. As Greg Rose says in his article about LBP and golf: "The lower back is rarely the original cause of the pain! It may be the current source of the pain, but it’s rarely the cause of the pain. More often than not, abnormal motions or forces coming from adjacent or distant areas of the body force the lower back to do excessive work until it completely breaks down itself." I am looking forward to further (respectfull) discussions.

  • Dr. Nathan Williams

    I'll jump in. While I don't refute the claims of visceral involvement in a small portion of patients with generalized back pain, it is, in my opinion, incorrect to propose that a major cause of spinal pain in golfers is of visceral origin.

  • Titleist Performance Institute

    This article seems to have struck a nerve (pun untended) with some of our readers. One of the things we pride ourselves on at TPI is our openness to either new ideas or different approaches. It’s this openness that was the genesis of TPI and the “body swing connection.” That being said, we allow all of our TPI Certified members to express their opinions and approaches via our article feed by submitting articles for review. Alternative opinions are welcomed and encouraged but please keep them respectful.

  • Anonymous User

    There is so much wrong in this article that I do not know where to begin.

  • Anonymous User

    I'm all for most of the recommendations contained within this article for various ailments. But I'm not convinced that the majority of back pain is caused due to kidney malposition (and several other comments within the article that struck me as wrong).

  • Anonymous User

    DC, DO, MD, DPT, etc. shouldn't matter. The information contained within an article is what is important. And the information contained within this article is largely incorrect. I'm very surprised to see Greg endorsing these sorts of thought processes.

  • Anonymous User

    I, too, am a chiropractor (and medical researcher). This article helps shed light on a holistic approach to injury prevention and rehabilitation quite nicely. However, I absolutely cannot support your ideas of visceral involvement as a major cause of back pain in golfers. My experience (and the literature) would very much disagree with you.

  • Anonymous User

    Would like to congratulate you all with the worst article I've read for years. Being able to put so much wrong information in one page is actually an achievement you all should be proud of. I've always thought of TPI as evidence-based and scientific, and then this quackery is being posted. Allowing the general public to believe that their KIDNEY is "misplaced" and this causes them back problem is just astonishing. I hope that this is something that is a one-off incidence and that TPI will soon go back into a scientific and evidence based approach to the game of golf.

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